Communicable Disease Surveillance Case Report Froms



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EDCP Mission/Vision

Fact Sheets

Case Report Forms

Hepatitis C

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Outbreak Investigation

Sexually Transmitted Diseases

Tuberculosis Control

Zoonotic and Vector-borne Diseases

Lyme Disease

Emerging Infections Program

Reportable Diseases: What to Report

Reportable Diseases: Counts and Rates

Case Report Forms

These forms should ONLY be used by Local Health Department staff during a case investigation. Citizens wishing to report the occurrence of a communicable disease should consult their Local Health Department by phone. Data collected on these forms should help determine if cases meet the appropriate CDC case definitions

Disease / Condition specific forms

Anthrax

Botulism

Meningitis (Aseptic)

Meningitis (Aseptic)

Botulism Infant

Meningitis (Bacterial)

Brucellosis

Meningococcal Disease

Cholera and Other Vibrio Illnesses

Mumps (Updated)

Cryptosporidiosis Supplement

Outbreak (See below)

Cyclospora

Perinatal Hepatitis B

Data and Specimen Handling (DASH)

Perinatal Hepatitis B Contact

Dengue

Diphteria

Pneumonia- Health Care Worker

Escherichia coli 0157:H7

Gastroenteritis Illness

Haemophilus Influenzae

Rickettsial (RMSF/Ehrlichiosis)

Hansen's Disease (Leprosy)

Rocky Mountain Spotted Fever

Hepatitis (Viral)

Rubella - Congenital

Hepatitis C (Initial)

Hepatitis C (Supplemental)

Influenza A- Novel (NOT 2009 H1N1)

Influenza-Associated Pediatric Death

Toxic Shock Syndrome

Influenza (2009 H1N1) Adult Death

Influenza (2009 H1N1) Clinical/ Pregnancy

Kawasaki Syndrome Printable

Typhoid and Paratyphoid Fever

Kawasaki Syndrome Fillable

Vaccine Adverse Event Reporting System(VAERS)

Legionellosis - CDC

Legionellosis - DHMHSupplemental

Varricella Death Investigation

Varicella Death Guidelines

West Nile Virus

West Nile Virus

Outbreak Final Report Forms

Long-Term Care Facility Forms	Adobe Acrobat	Microsoft Word
Gastroenteritis Outbreak	PDF	Word
Respiratory Outbreak	PDF	Word
Scabies Outbreak	PDF	Word
Drug Resistant Organism Outbreak	PDF	Word

Foodborne Outbreak Forms

National Outbreak Reporting System (NORS) Form 52.13	PDF	Word
National Outbreak Reporting System (NORS) Form 52.13 Guidance	PDF
National Outbreak Reporting System (NORS) Appendix	PDF

Other Forms

Daycare Facility Outbreak	PDF	Word
Hospital Outbreak (Excluding Gastroenteritis)	PDF	Word
Gastroenteritis Outbreak at a Hospital	PDF	Word
Pertussis Outbreak	PDF	Word
School Outbreak	PDF	Word
Waterborne Illness Outbreak	PDF	Word

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